COVID-19: Make it the Last Pandemic

 
COVID-19: Make it the Last Pandemic
COVID-19:
Make it the
Last Pandemic
COVID-19: Make it the Last Pandemic
Disclaimer:
The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the Independent Panel for Pandemic
Preparedness and Response concerning the legal status of any country, territory, city of area or
of its authorities, or concerning the delimitation of its frontiers or boundaries.

Report Design: Michelle Hopgood, Toronto, Canada
Icon Illustrator: Janet McLeod Wortel
Maps: Taylor Blake

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COVID-19: Make it the Last Pandemic
Contents

Preface4

Abbreviations6

1. Introduction                                                                   8

2. The devastating reality of the COVID-19 pandemic                               10

3. The Panel’s call for immediate actions to stop the COVID-19 pandemic           12

4. What happened, what we’ve learned and what needs to change                     15
4.1   Before the pandemic — the failure to take preparation seriously             15
4.2   A virus moving faster than the surveillance and alert system                21
4.2.1 The first reported cases                                                    22
4.2.2 The declaration of a public health emergency of international concern       24
4.2.3 Two worlds at different speeds                                              26

4.3   Early responses lacked urgency and effectiveness                            28
4.3.1 Successful countries were proactive, unsuccessful ones denied and delayed   31
4.3.2 The crisis in supplies                                                      33
4.3.3 Lessons to be learnt from the early response                                36

4.4   The failure to sustain the response in the face of the crisis               38
4.4.1 National health systems under enormous stress                               38
4.4.2 Jobs at risk                                                                38
4.4.3 Vaccine nationalism                                                         41

5. The Independent Panel’s recommendations                                        45

6. A roadmap forward                                                              62
Terms of reference for the Global Health Threats Council                          71

7. About the Panel and its work                                                   75

Acknowledgements80

References83
COVID-19: Make it the Last Pandemic
Preface
                               The COVID-19 pandemic is a sign of how vulnerable
                               and fragile our world is. The virus has upended societies,
                               put the world’s population in grave danger and exposed
                               deep inequalities. Division and inequality between and
                               within countries have been exacerbated, and the impact
                               has been severe on people who are already marginalized
                               and disadvantaged. In less than a year and a half,
                               COVID-19 has infected at least 150 million people
                               and killed more than three million. It is the worst
                               combined health and socioeconomic crisis in living
                               memory, and a catastrophe at every level.

                               The new millennium has seen the havoc which global health threats like
                               severe acute respiratory syndrome (SARS), Ebola and Zika can cause.
                               Experts have been warning of the threat of new pandemic diseases
                               and urged major changes in the way we protect against them — but the
                               change needed has not come about. As soon as a health threat or deadly
                               outbreak fades from memory, complacency takes over in what has been
                               dubbed a cycle of panic and neglect. This cycle must end.

                               COVID-19 is the 21st century’s Chernobyl moment — not because a disease
                               outbreak is like a nuclear accident, but because it has shown so clearly the
                               gravity of the threat to our health and well-being. It has caused a crisis so
                               deep and wide that presidents, prime ministers and heads of international
                               and regional bodies must now urgently accept their responsibility to
                               transform the way in which the world prepares for and responds to global
                               health threats. If not now, then when?

                               Our message for change is clear: no more pandemics.
                               If we fail to take this goal seriously, we will condemn
                               the world to successive catastrophes.
                               At the same time, our careful scrutiny of the evidence has revealed failures
                               and gaps in international and national responses that must be corrected.
                               Current institutions, public and private, failed to protect people from a
                               devastating pandemic. Without change, they will not prevent a future one.
                               That is why the Panel is recommending a fundamental transformation
                               designed to ensure commitment at the highest level to a new system
                               that is coordinated, connected, fast-moving, accountable, just, and
                               equitable — in other words, a complete pandemic preparedness and
                               response system on which citizens can rely to keep them safe and healthy.

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COVID-19: Make it the Last Pandemic
Given the devastation of this pandemic and its impact on people
                               everywhere, our findings are necessarily tough, and our recommendations
                               actionable.

                               Since September 2020, the Independent Panel has learned from many
                               stakeholders — front-line health workers, women, youth, mayors, ministers,
                               scientists, chief executive officers, international officials and diplomats. We
                               have also heard loud and clear that citizens are demanding an end to this
                               pandemic, and that is what they deserve. It is the responsibility of leaders
                               of all countries, as duty bearers, to respond to these demands.

                               The pandemic is not yet over — it is still killing more than 10 000 people
                               every day. Our recommendations are therefore directed first to the
                               immediate measures needed to curb transmission and to begin work
                               now to strengthen future protections. People in many countries continue
                               to suffer successive waves of infection - hospitals have again filled with
                               COVID-19 patients, and families are losing loved ones. The vaccines
                               available are a scientific triumph, but they must now be delivered across
                               the globe. At the time of writing, fewer than one in 100 people in low-
                               income countries had received a first dose — a graphic demonstration of
                               global inequality. As the virus spreads, it is also mutating and creating
                               new challenges.

                               We must work together to end this pandemic, and we must act urgently
                               to avert the next. Let history show that the leaders of today had the
                               courage to act.

                               Rt Hon. Helen Clark                         H.E. Ellen Johnson Sirleaf
                               Co-Chair                                    Co-Chair
                               Mauricio Cárdenas                           David Miliband
                               Aya Chebbi                                  Thoraya Obaid
                               Mark Dybul                                  Preeti Sudan
                               Michel Kazatchkine                          Ernesto Zedillo
                               Joanne Liu                                  Zhong Nanshan
                               Precious Matsoso

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COVID-19: Make it the Last Pandemic
Abbreviations

                                ACT-A                 Access to COVID-19 Tools Accelerator
                                Africa CDC            Africa Centres for Disease Control and Prevention
                                CEPI                  Coalition for Epidemic Preparedness Innovations
                                COVAX Facility        COVID-19 Vaccines Global Access Facility
                                COVID-19              coronavirus disease
                                Global Fund           Global Fund to Fight AIDS, Tuberculosis and Malaria
                                IHR (2005)            International Health Regulations (2005)
                                IMF                   International Monetary Fund
                                MERS                  Middle East respiratory syndrome
                                MS                    Member States
                                ODA                   official development assistance
                                PHEIC                 public health emergency of international concern
                                PPE                   personal protective equipment
                                ProMED                Program for Monitoring Emerging Diseases
                                R&D                   research and development
                                SARS                  severe acute respiratory syndrome
                                SARS-CoV-2            severe acute respiratory syndrome coronavirus 2
                                WHA                   World Health Assembly
                                WTO                   World Trade Organization

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COVID-19: Make it the Last Pandemic
Credit: Rosem
        Watsamon
              Morton
                 Tri-Yasakda
COVID-19: Make it the Last Pandemic
1. Introduction

                               The world is still in the midst of a pandemic that has
                               spread wider and faster than any in human history.
                               The social and economic crisis precipitated by COVID-19
                               is affecting families, communities and nations across
                               the globe.

                               Seized by the gravity of the crisis, in May 2020 the World Health
                               Assembly requested the Director-General of WHO to initiate an impartial,
                               independent, and comprehensive review of the international health
                               response to COVID-19 and of experiences gained and lessons learned
                               from that, and to make recommendations to improve capacities for the
                               future. The Director-General asked H.E. Ellen Johnson Sirleaf and the
                               Rt Hon. Helen Clark to convene an independent panel for this purpose
                               and to report to the World Health Assembly in May 2021.

                               The Panel has taken a systematic, rigorous and comprehensive approach
                               to its work. It has sought to listen to and learn from a wide range of
                               interlocutors. Since mid-September 2020, the Panel has reviewed
                               extensive literature, conducted original research, heard from experts
                               in 15 round-table discussions and in interviews, received the testimony
                               of people working on the front lines of the pandemic in town-hall-style
                               meetings, and welcomed many submissions from its open invitation
                               to contribute.

                               The Panel has examined the state of pandemic preparedness prior
                               to COVID-19, the circumstances of the identification of severe acute
                               respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease
                               it causes, coronavirus disease (COVID-19), and responses globally,
                               regionally and nationally, particularly in the pandemic’s early months.
                               It has also analysed the wide-ranging impact of the pandemic and
                               the ongoing social and economic crisis that it has precipitated.

                               This report presents the Panel’s findings on what happened, the lessons
                               to be learned from that, and our recommendations for strategic action
                               now to end this pandemic and to ensure that any future infectious disease
                               outbreak does not become a catastrophic pandemic.

                               Complementing this report, the Panel presents a companion report
                               describing thirteen defining moments which have been pivotal in shaping
                               the course of the pandemic. In addition, the Panel is publishing a series
                               of background papers representing in-depth research including a
                               chronology of the early response.

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The recommendations are ambitious and crucial. The Panel believes that
                                       the international system requires fundamental transformation to prevent
                                       a future pandemic. The Panel calls on political decision-makers at every
                                       level to champion major change and to make available the resources to
                                       make it effective. The ask is large and challenging, but the prize is even
                                       larger and more rewarding. With so many lives at stake, now is the time
                                       for resolve.

                           The ask is large and challenging, but the prize is even
                           larger and more rewarding. With so many lives at stake,
                           now is the time for resolve.

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Credit: Tuane Fernandes Silva
COVID-19: Make it the Last Pandemic
2. The devastating reality
   of the COVID-19 pandemic

                               COVID-19 has shown how an infectious disease can sweep
                               the globe in weeks and, in the space of a few months, set
                               back sustainable development by years.

                               By all measures, the impact of the pandemic is massive:

                                   • 148 million people were confirmed infected and more than
                                     3 million have died in 223 countries, territories and areas
                                     (as at 28 April 2021) (1);
                                   • at least 17 000 health workers died from COVID-19 during
                                     the pandemic’s first year (2);
                                   • US$ 10 trillion of output is expected to be lost by the end of 2021,
                                     and US$ 22 trillion in the period 2020–2025 — the deepest shock to
                                     the global economy since the Second World War and the largest
                                     simultaneous contraction of national economies since the Great
                                     Depression of 1930–32 (3);
                                   • At its highest point in 2020, 90% of schoolchildren were unable
                                     to attend school (4);
                                   • 10 million more girls are at risk of early marriage because
                                     of the pandemic (5);
                                   • gender-based violence support services have seen fivefold
                                     increases in demand (6);
                                   • 115–125 million people have been pushed into extreme poverty (7).

                               The language of health statistics and economics cannot convey the
                               depth of disruption as COVID-19 has overturned people’s lives. People
                               are grieving the loss of their loved ones, and those with long-term health
                               impacts from the disease continue to suffer. There are instances where
                               people with cancer have been unable to attend chemotherapy sessions,
                               and people with suspected tuberculosis have not been diagnosed or
                               treated. Market sellers have been unable to work and put food on the
                               table. Women have found their double workload tripled or quadrupled,
                               as they try to maintain the family income, care for the elderly and sick,
                               become teachers for their home-schooled children, and maintain the
                               well-being of their families.

                               Most dispiriting is that those who had least before the pandemic have
                               even less now. The experience of previous epidemics shows that income
                               inequality increased in affected countries over the five years following
                               each event. Those working in the informal sector have had little or no
                               support. Migrants, refugees, and displaced people have often been

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shut out of testing services and health facilities. Perhaps 11 million of the
                                      poorest girls in the world may never go back to the classroom (8). People
                                      living in the poorest countries are at the tail-end of the vaccine queue.

                                      It does not have to be this way.

                                      A groundswell of opinion is determined to address inequality so that
                                      we can come out of the pandemic looking forward to a better world,
                                      sustaining and expanding responses where they have shown a better
                                      path. Governments have offered income support to millions of people in
                                      places where, before the pandemic, that had been considered a political
                                      impossibility. Campaign-based health services, like immunization, have
                                      bounced back rapidly. Service delivery in health is being changed for the
                                      better through people-centred initiatives, such as those in telemedicine or
                                      with the multi-month dispensing of medications. The links between green
                                      and sustainable futures and a pandemic-free world are being drawn
                                      more clearly than ever before.

                                      Ending this pandemic as quickly as possible goes hand in hand with
                                      preparing to avert another one. Paying attention to what went wrong, as
                                      well as to what went right, will be invaluable pointers to ways in which the
                                      world can get back on track to realise the 2030 Agenda for Sustainable
                                      Development.

                                      This pandemic has shaken some of the standard assumptions that a
                                      country’s wealth will secure its health. Leadership and competence
                                      have counted more than cash in pandemic responses. Many of the best
                                      examples of decisive leadership have come from governments and
                                      communities in more resource-constrained settings. There is a clear
                                      opportunity to build a future beyond the pandemic that draws on the
                                      wellsprings of wisdom from every part of the world.

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Credit: Angela Ponce
3. The Panel’s call for immediate actions
   to stop the COVID-19 pandemic

                               The Panel is deeply concerned and alarmed about the
                               current persistent high levels of transmission of SARS-
                               CoV-2, which are driving illness and deaths, and about
                               the development of virus variants all of which continue to
                               impose an intolerable burden on societies and economies.

                               Countries have varied significantly in their application of public health
                               measures to keep the spread of the virus in check. Some have sought to
                               contain the epidemic aggressively and drive towards elimination; some
                               have aimed at virus suppression; and some have aimed just to mitigate
                               the worst impacts. Countries with the ambition to aggressively contain
                               and stop the spread whenever and wherever it occurs have shown that
                               this is possible. Given what is known already, all countries should apply
                               public health measures consistently and at the scale the epidemiological
                               situation requires. Vaccination alone will not end this pandemic. It must
                               be combined with testing, contact-tracing, isolation, quarantine, masking,
                               physical distancing, hand hygiene, and effective communication with
                               the public.

                               Alongside these non-pharmaceutical measures, vaccine rollout needs
                               to be scaled up urgently and equitably across the world. A number of
                               effective vaccines are now approved. Current production capacity,
                               however, is stretched close to its limits, and vaccination coverage is far
                               from being at the scale needed to reduce the burden of illness and curb
                               transmission globally.

                               The uneven access to vaccination is one of today’s pre-eminent
                               global challenges. High-income countries have over 200% population
                               coverage of vaccine doses, obtained mainly through bilateral deals with
                               manufacturers to secure existing and future stocks. In many cases low-
                               and middle-income countries have been shut out of these arrangements.
                               In the poorest countries, at the time of finalising this report, fewer than
                               1% of people have had a single dose of vaccine. The COVID-19 Vaccines
                               Global Access Facility (COVAX Facility), rapidly established with the
                               intention of ensuring global, equitable access, is making good progress
                               but has been hampered in that goal by a lack of sufficient funds and by
                               vaccine nationalism, and now, vaccine diplomacy.

                   There are 5.7 billion people in the world aged 16 and over.
                   All need access to safe and effective COVID-19 vaccines.
                   This is not some aspiration for tomorrow — it is urgent, now.

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To prepare ourselves for new phases of the COVID-19 pandemic and to
                                      respond effectively, a global strategy with clear goals, milestones and
                                      priority actions is needed. The significant inequity in vaccine access must
                                      be addressed immediately, as it is not only unjust, but also threatens the
                                      effectiveness of global efforts to control the pandemic. Variants may still
                                      emerge that our vaccines cannot manage. The more quickly we vaccinate
                                      now, the less likelihood there is of ever more variants emerging. One
                                      action which can be taken now is an equitable redistribution of available
                                      vaccine doses. Scaling up the development and supply of therapeutics
                                      and of diagnostic tests is also very urgent to save lives.

                                      Moreover, to prepare for likelihood of of COVID-19 becoming endemic
                                      and to address inequity in vaccine access in a more sustained way,
                                      manufacturing capacity of mRNA and other vaccines must urgently
                                      be built in Africa, Latin America and other low- and middle-income
                                      regions. Vaccine manufacturing is highly specialized and difficult.
                                      Boosting production takes time so enabling it must begin now. It requires
                                      agreements on voluntary licensing and technology transfer.

                                      There are 5.7 billion people in the world aged 16 and over. All need
                                      access to safe and effective COVID-19 vaccines. This is not some
                                      aspiration for tomorrow — it is urgent, now. COVAX has secured 1.1 billion
                                      vaccine doses and has optioned 2.5 billion more (9). Before the end of
                                      April, one billion vaccine doses were administered, overwhelmingly in
                                      high-income or upper-middle-income countries. The Panel joins with
                                      political and faith leaders across the world and calls for an all-out
                                      effort to reach the world’s population with vaccines within a year and
                                      set in place the infrastructure needed for at least 5 billion booster
                                      doses annually.

                                      Immediate action to end COVID-19 must be guided by explicit strategies
                                      with measurable milestones. The Panel recognizes the WHO COVID-19
                                      Strategic Preparedness and Response Plan for 2021 (10) provides useful
                                      technical guidance but the Panel’s view is that there is a need for a
                                      higher level roadmap for ending the pandemic with clear targets,
                                      milestones and dates.

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Credit: Mindy Tan
The Independent Panel makes
                               the following urgent calls
                               I.    Apply non-pharmaceutical public health measures systematically
                                     and rigorously in every country at the scale the epidemiological
                                     situation requires. All countries to have an explicit evidence-based
                                     strategy agreed at the highest level of government to curb
                                     COVID-19 transmission.
                               II.   High income countries with a vaccine pipeline for adequate
                                     coverage should, alongside their scale up, commit to provide to
                                     the 92 low and middle income countries of the Gavi COVAX Advance
                                     Market Commitment, at least one billion vaccine doses no later than
                                     1 September 2021 and more than two billion doses by mid-2022, to be
                                     made available through COVAX and other coordinated mechanisms.
                               III. G7 countries to commit to providing 60% of the US$ 19 billion
                                    required for ACT-A in 2021 for vaccines, diagnostics, therapeutics
                                    and strengthening health systems with the remainder being
                                    mobilised from others in the G20 and other higher income countries.
                                    A formula based on ability to pay should be adopted for predictable,
                                    sustainable, and equitable financing of such global public goods
                                    on an ongoing basis.
                               IV.   The World Trade Organization and WHO to convene major
                                     vaccine-producing countries and manufacturers to get agreement
                                     on voluntary licensing and technology transfer arrangements for
                                     COVID-19 vaccines (including through the Medicines Patent Pool).
                                     If actions do not occur within three months, a waiver of intellectual
                                     property rights under the Agreement on Trade-Related Aspects of
                                     Intellectual Property Rights should come into force immediately.
                               V.    Production of and access to COVID-19 tests and therapeutics,
                                     including oxygen, should be scaled up urgently in low- and middle-
                                     income countries with full funding of US$1.7 billion for needs in 2021
                                     and the full utilization of the US$3.7 billion in the Global Fund’s
                                     COVID-19 Response Mechanism Phase 2 for procuring tests,
                                     strengthening laboratories and running surveillance and tests.
                               VI. WHO to develop immediately a roadmap for the short-term,
                                   and within three months scenarios for the medium- and long-term
                                   response to COVID-19, with clear goals, targets and milestones
                                   to guide and monitor the implementation of country and global
                                   efforts towards ending the COVID-19 pandemic.

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4. What happened, what we’ve learned
   and what needs to change

                               The Panel has carefully reviewed each phase of the
                               present crisis in order to establish facts and draw lessons
                               for the future.

                               4.1 Before the pandemic — the failure to take
                                   preparation seriously
                               In under three months from when SARS-CoV-2 was first identified as
                               the cause of clusters of unusual pneumonia cases in Wuhan, China,
                               COVID-19 had become a global pandemic threatening every country in the
                               world (11). Although public health officials, infectious disease experts, and
                               previous international commissions and reviews had warned of potential
                               pandemics and urged robust preparations since the first outbreak of
                               SARS, COVID-19 still took large parts of the world by surprise. It should
                               not have done. The number of infectious disease outbreaks has been
                               accelerating, many of which have pandemic potential.

                               It is clear to the Panel that the world was not prepared and had ignored
                               warnings which resulted in a massive failure: an outbreak of SARS-COV-2
                               became a devastating pandemic.

                               The fast-moving SARS epidemic had shaken the world in 2003. While
                               the epidemic only lasted some six months and was responsible for 8096
                               cases and 774 deaths (12), it was judged by the WHO Regional Director
                               for the Western Pacific to have “caused more fear and social disruption
                               than any other outbreak of our time” (13). SARS was a novel coronavirus
                               causing respiratory disease. It travelled rapidly to 29 countries, territories
                               and areas, and debilitated health systems, with many health workers
                               being infected. Even so, expert observers knew that, with SARS, the world
                               had dodged a bullet — screening and isolation could readily contain its
                               spread, because people with SARS did not transmit the virus until several
                               days after showing symptoms and were most infectious when symptoms
                               were most severe. It was understood that if a new fast-moving pathogen
                               were transmissible in the absence of symptoms, it would pose a much
                               deadlier challenge.

                               The SARS epidemic was followed by the 2009 H1N1 influenza pandemic,
                               the 2014–2016 Ebola outbreak in west Africa, Zika and other disease
                               outbreaks, including another new coronavirus, Middle East respiratory
                               syndrome (MERS). These outbreaks were the impetus for a series of
                               initiatives to strengthen health security, animated by the conviction that
                               disease outbreaks and other health threats constituted a major global risk
                               and required a web of actions across all countries.

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SARS propelled the decade-long negotiations to revise and broaden the
                               International Health Regulations (IHR) to a rapid conclusion. The current
                               regulations were adopted in 2005, setting out legally binding duties for
                               both States and WHO in notification and information-sharing, prohibitions
                               on unnecessary interference with international travel and trade, and
                               cooperation for the containment of disease spread. The new IHR (2005)
                               came into force in 2007 and imposed new requirements that must be met
                               before the WHO Director-General could act on emergencies, rather than
                               enabling WHO to act immediately and independently.

                               Groups of States also took initiatives to boost health security. The Global
                               Health Security Initiative was established in 2001 by eight States and the
                               European Commission, with WHO as an observer. The Global Health
                               Security Action Group was its implementation and information-sharing
                               body. The Global Health Security Agenda was launched by the United
                               States in partnership with two dozen other countries in 2014 and has
                               now grown to include seventy countries and a number of international
                               organizations. It has sought to complement efforts to strengthen IHR
                               (2005) implementation, including through support for voluntary Joint
                               External Evaluations. The fact, however, that not all States participate in the
                               Agenda and its related processes has limited its effectiveness and reach.

                    Despite the consistent messages that significant change was
                    needed to ensure global protection against pandemic threats,
                    the majority of recommendations were never implemented.

                               Since the 2009 H1N1 influenza pandemic, at least 11 high-level panels
                               and commissions have made specific recommendations in 16 reports to
                               improve global pandemic preparedness. Many concluded that the World
                               Health Organization needed to strengthen its role as the leading and
                               coordinating organization in the field of health, focus on its normative
                               work, and receive more secure funding. Reviews also suggested
                               improvements in the implementation of the IHR (2005). Some of
                               the reviews resulted in specific action, including the establishment
                               of the new WHO Health Emergencies Programme in 2016.

                               Yet, despite the consistent messages that significant change was needed
                               to ensure global protection against pandemic threats, the majority of
                               recommendations were never implemented. At best, there has been
                               piecemeal implementation. A coalition of interests with sufficient power
                               and momentum to achieve a package of essential reforms has never been
                               assembled. As a result, pandemic and other health threats have not been
                               elevated to the same level of concern as threats of war, terrorism, nuclear
                               disaster or global economic instability. When steps have been explicitly
                               recommended, they have been met with indifference by Member States,
                               resulting in weakened implementation that has severely blunted the
                               original intentions. It is clear to the Panel that pandemics pose potential
                               existential threats to humanity and must be elevated to the highest level.

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The United Nations High-level Panel on the Global Response to
                               Health Crises, chaired by President Kikwete of the United Republic
                               of Tanzania, was established in response to the 2014–2016 epidemic
                               of Ebola. It recommended that the United Nations General Assembly
                               should immediately create a high-level council on global public health
                               crises. On receiving its report, the United Nations Secretary-General
                               Ban Ki-moon established a task force to oversee implementation of its
                               recommendations. The task force’s report in June 2017 recommended that
                               the Secretary-General implement a time-limited independent mechanism
                               for reporting on the world’s preparedness, rather than the high-level
                               independent council which had been recommended by the Kikwete-led
                               panel. The outcome was the establishment of the Global Preparedness
                               Monitoring Board in May 2018, with its members appointed by the heads
                               of WHO and the World Bank.

                               National pandemic preparedness has been vastly underfunded, despite
                               the clear evidence that its cost is a fraction of the cost of responses
                               and losses incurred when an epidemic occurs. The total cost of the
                               economic losses due to SARS was estimated at US$ 60 billion (14). The
                               2015 MERS outbreak in just one country, the Republic of Korea, with 185
                               cases and 38 deaths, cost US$ 2.6 billion in lost tourism revenue and US$
                               1 billion in response costs (15). The 2016 Commission on a Global Health
                               Risk Framework for the Future argued that its proposed preparedness
                               spending boost of US$ 4.5 billion annually was a small investment
                               compared with a scenario of the potential global cost of pandemics
                               over the whole of the 21st century, which they assessed as being
                               “in excess of $6 trillion” (16).

              “…the Panel notes that the high risk of major health crises is
              widely underestimated, and that the world’s preparedness and
              capacity to respond is woefully insufficient. Future epidemics
              could far exceed the scale and devastation of the West Africa
              Ebola outbreak.”
                              From: Protecting humanity from future health crises Report of the High-level
                                           Panel on the Global Response to Health Crises, February 2016.

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While there have been concerted efforts in recent years to boost
                                          pandemic preparedness, they have fallen far short of what is required.
                                          Too many national governments lacked solid preparedness plans, core
                                          public health capacities and organized multisectoral coordination with
                                          clear commitment from the highest national leadership (17). The self-
                                          reported assessment of core capacities for preparedness that countries
                                          are required to submit to the WHO under IHR (2005) gave a global
                                          average score of 64 out of 100 (18). Only two-thirds of countries reported
                                          having full enabling legislation and financing to support needed health
                                          emergency prevention, detection, and response capabilities (19). Country
                                          preparedness was also assessed under the voluntary Joint External
                                          Evaluation process, undertaken to date by 98 countries. An independent
                                          academic exercise, the Global Health Security Index, also sought to score
                                          country pandemic preparedness.

    Figure 1: Death rates in this figure shows the cumulative, reported, age-standardized to COVID-19 deaths per
    hundred thousand people in the 50 days following the date of the first death in that country
    Source and adapted from: Sawyer Crosby et al, IHME, Think Global Health

                                       Joint External Evaluation Scores vs. COVID-19 Death Rates

               32.2
 Death Rate

                                                                                                                                  BEL

               16.1                     STP

                                                                                                                                          CHE
                  8                                                                                           KWT           USA
                                                                                                                                           ARE

                                 DJI                                                                                                             CAN
                  4                                                            MKD
                                                            MDV
                                                                                  MDA                                       SVN    FIN
                             GNB                                                                                    SAU
                  2                                   SLE                                           QAT
                                              CMR                                                                               OMN
                           TCD                                  LBR                                                                        ARM
                                                                            SRB
                   1                                              PAK                      ALB
                                                                                                               LTU
                         GAB                                                                                              BHR
                                              AFG                                                ZAF
                                                                               MUS                 MAR
                               COG                        SEN
                0.5                                                      LBN                                  LVA
                                                    CIV                        TUN
                                                            IRQ KEN                                             KGZ                 NZL          SGP
                                          TGO                                                IDN
                0.3                                                      SDN
                                        COD               GHA             GEO
                                                                                     JOR
                0.1                                              BGD
                                                                                                                                           AUS
                                GMB

                0.1                                             BGD
                            MWI
                                        BEN     ZWE LBY

                                                                      PHL                                           THA
                  0                                                            LKA
                                                                                                                                           JPN
                                 BDI                                  ETH
                  0

                                  30            40                50                 60                  70               80              90
                                                                Joint External Evaluation Score

              Central/Eastern Europe & Central Asia         North Africa & Middle East             Southeast/East Asia & Oceania           High-income
              Latin America & Caribbean                     South Asia                             Sub-Saharan Africa

COVID-19: Make it the Last Pandemic by The Independent Panel for Pandemic Preparedness & Response                                                     18 of 86
What all these measures have in common was that their ranking
                                of countries did not predict the relative performance of countries
                                in the COVID-19 response (20, 21, 22). The measures failed to account
                                sufficiently for the impact on responses of political leadership, trust in
                                government institutions and country ability to mount fast and adaptable
                                responses (23). For example, while the US ranked highest in its aggregate
                                score on the Global Health Security Index, it scored less well on universal
                                health care access, and in relation to public confidence in government
                                received a score of zero indicating a confidence level of less than 25% (24).
                                The failure of these metrics to be predictive demonstrates the need
                                for a fundamental reassessment which better aligns preparedness
                                measurement with operational capacities in real-world stress situations,
                                including the points at which coordination structures and decision-making
                                may fail. The current pandemic will generate a wealth of data to guide
                                that reassessment.

                                Underscoring the consequences of a failure to invest sufficiently in
                                preparedness capacity is the increasing background level of risk.
                                Population growth and accompanying environmental stresses are driving
                                an increase in emerging novel pathogens. Air travel, which has increased
                                fourfold since 1990, enables a virus to reach any place in the world in a
                                matter of hours (25). A new pathogen could emerge and spread at any time.

                                Most of the new pathogens are zoonotic in origin. Driving their increasing
                                emergence are land use and food production practices and population
                                pressure. Global surveillance systems need to monitor burgeoning
                                infrastructure, environmental loss and the status of animal health.
                                One Health interagency and multisectoral collaboration need to be an
                                integral part of pandemic preparedness planning. Accelerating tropical

  Figure 2: Air travel has increased four-fold since 1990. This figure shows concurrent flights in the air
  as of 02 May 2021, 9pm CET
  Source: FlightAware, accessed online 2 May 2021.

COVID-19: Make it the Last Pandemic by The Independent Panel for Pandemic Preparedness & Response           19 of 86
Pandemic preparedness planning is a core function of
                   governments and of the international system and must be
                   overseen at the highest level. It is not a responsibility of the
                   health sector alone.

                               deforestation and incursion destroys wildlife health and habitat and
                               speeds interchange between humans, wildlife and domestic animals.
                               The threats to human, animal and environmental health are inextricably
                               linked, and instruments to address them need to include climate change
                               agreements and “30x30” global biodiversity targets (26, 27).

                               SARS-CoV-2 is just such a virus of zoonotic origin whose emergence
                               was highly likely. Current evidence suggests that a species of bat is
                               the most likely reservoir host. The intermediate host is still unknown,
                               as is the exact transmission cycle. WHO convened a technical mission
                               to better understand the origins of the virus (28). While the mission has
                               now reported, investigations of the origins of the virus will continue. The
                               experience of other pandemics, such as HIV, suggest that it will be some
                               time, possibly years, before there is an accepted consensus about how
                               and when the virus first infected humans and when and where the first
                               human-to-human transmission clusters occurred. There is some evidence,
                               based both on reconstructions looking backwards in time at the likely
                               epidemiology and through the analysis of samples collected and stored,
                               that the virus may already have been in circulation outside China in
                               the last months of 2019. This evidence, however, still requires further
                               examination, and confounding explanations, such as the contamination
                               of samples, are still to be ruled out.

                               COVID-19 exposed a yawning gap between limited, disjointed efforts
                               at pandemic preparedness and the needs and performance of a
                               system when actually confronted by a fast-moving and exponentially
                               growing pandemic.

                               The Panel’s conclusion is that closing the preparedness gap not only
                               requires sustained investment, it requires a new approach to measuring
                               and testing preparedness. Drills and simulation exercises resulting in
                               immediate rectification of identified weaknesses must become routine,
                               and preparedness assessment must place more focus on the way the
                               system functions in actual conditions of pandemic stress.

                               Zoonotic outbreaks are becoming more frequent, increasing the urgency
                               for better detection and more robust preparedness. Given the increasing
                               stakes, monitoring pandemic threat needs to be on the agenda of
                               decision-makers at the highest levels of governmental, intergovernmental,
                               corporate and community organizations.

                               Pandemic preparedness planning is a core function of governments and
                               of the international system and must be overseen at the highest level.
                               It is not a responsibility of the health sector alone.

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4.2 A virus moving faster than the surveillance
                                   and alert system
                               The earliest possible recognition of a novel pathogen is critical to
                               containing it. The emergence of COVID-19 was characterized by a mix
                               of some early and rapid action, but also by delay, hesitation, and denial,
                               with the net result that an outbreak became an epidemic and an epidemic
                               spread to pandemic proportions.

                               The Independent Panel has consulted widely in order to develop a
                               meticulous and verified chronology of events as they took place from
                               the end of 2019 when cases were first detected in China through to
                               the end of March 2020, by when the outbreak had spread extensively
                               worldwide and had been characterized as a pandemic. Inputs to this
                               chronology have included a systematic review of all the relevant published
                               studies — both those that were available at the time and retrospective
                               studies; submissions from WHO Member States, interviews with key actors
                               in China and other countries, with WHO and other organizations; and
                               a review of internal documents and correspondence from WHO.

                               The intention of the Panel in examining in detail the steps taken to
                               respond to COVID-19 is not to assign blame, but rather to understand
                               what took place and what, if anything, could be done differently if
                               similar circumstances arise again, as they almost certainly will. We are
                               conscious that our judgements benefit from the wisdom of hindsight and
                               acknowledge that the decisions made at the time were made in conditions
                               of great uncertainty.

  Figure 3: A short segment of the authoritative chronology of the Independent Panel
  Source: The Independent Panel for Pandemic Preparedness and Response

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4.2.1 The first reported cases
                                        In December 2019, a number of patients with pneumonia of
                                        unknown origin were admitted to hospitals in Wuhan, China.
                                        Later tests on a cohort of patients admitted between 16 December
                                        and 2 January found 41 with COVID-19. On 24 December, doctors
                                        concerned about a pneumonia patient not responding to the
                                        usual treatments sent a sample to a private laboratory for testing.
                                        Clinicians noticed that a number of patients — although not all —
                                        had attended the Huanan Seafood Market in Wuhan. For example,
                                        in a family group, a woman who was treated on 26 December
                                        had attended the seafood market, while her husband and son,
                                        whose chest scans were conducted shortly thereafter and showed
                                        similar patterns, had not. While the market was the initial focus
                                        of investigation, two later studies (29, 30) of the early laboratory-
                                        confirmed cases linked only 55–66% of cases to exposures there,
                                        suggesting that the market may have been a site of amplification of
                                        the virus rather than its origin. The evidence of human-to-human
                                        transmission of a new pathogen was not definitive in December 2019
                                        but by the end of the month there were signs of it being likely.
                                        On 30 December 2019, the Wuhan Municipal Health Commission
                                        issued two urgent notices to hospital networks in the city about
                                        cases of pneumonia of unknown origin linked to the Huanan
                                        Seafood Market. The market was closed and cleaned between
                                        31 December and 1 January. On the morning of 31 December,
                                        Chinese business publication Finance Sina reported on one of
                                        the notices issued by the Wuhan Municipal Health Commission.
One of the urgent                       This report was replicated and picked up by several disease
notices issued on
                                        surveillance systems, including the Centers for Disease Control,
30 December 2019 by
the Wuhan Municipal                     Taiwan, China, which in turn contacted WHO via email through
Health Commission.                      the IHR (2005) reporting system, requesting further information.
                                        A machine translation of the Finance Sina report was published
                                        on the website of the Program for Monitoring Emerging Diseases
                                        (ProMED). This report was picked up by the Epidemic Intelligence
                                        from Open Sources (EIOS) system and alerted WHO Headquarters
                                        to the outbreak. Later in the afternoon of 31 December, the Wuhan
                                        Municipal Health Commission issued a public bulletin describing 27
                                        cases of pneumonia of unknown origin. The WHO Country Office
                                        in China took note of the bulletin shortly after it was posted and
                                        immediately informed the IHR focal point in the WHO Western
                                        Pacific Regional Office (WPRO).
                                        The Wuhan Institute of Virology sequenced almost the entire
                                        genome of the virus on 2 January 2020. On 5 January 2020, the
                                        complete genetic sequence was submitted to the open-access
                                        website GenBANK from a sample sequenced by the Shanghai
                                        Public Health Centre and this was made public on 11 January (31),
                                        and further sequences were uploaded by the China CDC. The
                                        China CDC successfully isolated the virus by 7 January 2020.
                                        Chinese scientists developed a PCR testing reagent for the virus
                                        by 10 January 2020 (29).

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These events, as they unfolded in Wuhan in the last two weeks of
                                      December 2019 and into January 2020, demonstrate the diligence
                                      of clinicians who noticed clusters of unusual pneumonia, sent samples
                                      for screening where commercially available next-generation
                                      sequencing detected signs indicative of a new SARS-like
                                      coronavirus, and escalated their concerns about this cluster of
                                      unexplained disease to local health authorities. The local health
                                      authorities closed and cleaned the market that was suspected
                                      as a potential source of the virus.
                                      Within a day of the local alert being issued to hospitals, it was
                                      noted in the media. The signal was picked up by other health
                                      authorities and by the global epidemic surveillance networks that
                                      constantly scour open sources around the world. There were thus
                                      three routes through which WHO became aware of the outbreak
                                      on 31 December 2019 — the Centers for Disease Control, Taiwan,
                                      China contacting WHO through the IHR (2005) reporting system
                                      after noting media references to the outbreak; the alert published
                                      on the ProMED website and picked up by the epidemic surveillance
                                      system; and the WHO Country Office in China noting the public
                                      bulletin from the Wuhan Municipal Health Commission.

                   These events, as they unfolded in Wuhan in the last
                   two weeks of December 2019 and into January 2020,
                   demonstrate the diligence of clinicians who noticed
                   clusters of unusual pneumonia

                                      On 1 January 2020, WPRO formally requested further information;
                                      and on 3 January it requested verification under the IHR (2005)
                                      Article 10 procedures. The Chinese National Health Commission and
                                      the Country Office met for a technical briefing on 3 January and
                                      provided initial information about the first set of 44 reported cases
                                      during the briefing and by email. The WHO subsequently published
                                      a Twitter thread about the cases on 4 January, and on 5 January
                                      officially alerted all country governments through the IHR Event
                                      Information System, as well as issuing its first Disease Outbreak
                                      News notice on the cluster.
                                      The Chinese authorities and WHO held a subsequent briefing on
                                      11 January. The Country Office reached an agreement with Chinese
                                      authorities on 15 January to visit Wuhan. On 16 January, a further
                                      briefing was held, and a more complete list of case information
                                      was shared. The first WHO mission to Wuhan took place on
                                      20–21 January.
                                      In an announcement on national television on 20 January 2020
                                      Chinese health experts confirmed publicly that human to human
                                      transmission was occurring and that health workers were among
                                      those who had become infected. Wuhan instituted a drastic

COVID-19: Make it the Last Pandemic by The Independent Panel for Pandemic Preparedness & Response   23 of 86
population lockdown on 23 January to try to contain the virus,
                                      as 830 cases and 25 deaths were reported (32). According to the report
                                      of the second joint WHO-China mission, which took place from 16
                                      to 24 February, the lockdown and public health measures taken in
                                      China were considered successful in rapidly reducing transmission.
                                      Some places began screening incoming visitors almost immediately,
                                      as news of the Wuhan outbreak became public. Meanwhile in
                                      Thailand, a case was confirmed on 13 January of a woman who
                                      had travelled there from Wuhan on 8 January, the first case to be
                                      confirmed outside China. Japan reported an infected person on
                                      16 January.

                                      4.2.2 The declaration of a public health emergency
                                            of international concern
                                      A Public Health Emergency of International Concern (PHEIC) is the
                                      loudest alarm that can be sounded by the WHO Director-General.
                                      The IHR (2005) mandate that in determining whether an event
                                      constitutes a PHEIC, the WHO Director-General consider the advice
                                      of an Emergency Committee convened for the purpose and drawn
                                      from a roster of experts maintained by WHO. The affected State is
                                      invited to present its views to the Emergency Committee. If a PHEIC
                                      is recommended, the WHO Director-General has the final authority
                                      to make a declaration, taking all information into account. The
                                      meeting of the WHO IHR Emergency Committee called to discuss
                                      the outbreak on 22–23 January was split on whether to recommend
                                      that the outbreak be declared a PHEIC. The Committee met again
                                      the following week when the Director-General returned from a
                                      mission to China. Following the Committee’s recommendation, the
                                      WHO Director-General declared that the outbreak constituted a
                                      PHEIC on 30 January. At that time there were 98 cases in 18 countries
                                      outside China (33, 34). In the statement from the Emergency Committee
                                      reported by the Director-General, it was specified that no travel
                                      restrictions were recommended, based on the information available.
                                      Reference to the PHEIC outbreak was included in the 3 February
                                      2020 report by the WHO Director-General to the WHO Executive
                                      Board (35). On 4 February in an oral briefing to Member States
                                      he reported that there had been 20 471 confirmed cases and
                                      425 deaths reported in China, and a total of 176 cases in 24
                                      other countries.
                                      The IHR (2005) do not use or define the term “pandemic”. The most
                                      extensive use of the term by WHO is in relation to the detailed
                                      framework and guidelines for pandemic influenza, although even
                                      there the distinction between seasonal and pandemic influenza is
                                      not clear-cut (36). As COVID-19 spread during February 2020, and
                                      there was an apparent lack of understanding that declaring a PHEIC
                                      was to sound the loudest possible alarm, there was an increasing
                                      clamour for WHO to describe the situation as a pandemic.
                                      Eventually, stating that it was alarmed by the extent of both the
                                      spread of the disease and the level of inaction in response, WHO

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went on to characterize COVID-19 as a global pandemic
                                      on 11 March 2020, when there were a reported 118 000 cases
                                      in 114 countries (37).
                                      The Panel has considered this sequence of events between
                                      December 2019 and the declaration of a PHEIC on 30 January 2020
                                      in detail in order to assess what could potentially have been done
                                      differently and whether changes are needed in the international
                                      system of alert.

                   There is a case for applying the precautionary principle
                   in any outbreak caused by a new pathogen resulting
                   in respiratory infections, and thereby for assuming that
                   human-to-human transmission will occur unless the
                   evidence specifically indicates otherwise

                                      The IHR (2005) are designed to ensure that countries have the
                                      capacity to detect and notify health events. They require that, when
                                      disease or deaths above expected levels are detected, essential
                                      information is reported immediately to subnational or national
                                      levels. If urgent events, defined as having “serious public health
                                      impact and/or unusual or unexpected nature with high potential
                                      for spread” are detected, they must be reported immediately to
                                      the national level and assessed within 48 hours. Events assessed to
                                      warrant a potential PHEIC must be reported to WHO within 24 hours
                                      of assessment, via the IHR national focal point. Events with PHEIC
                                      potential must meet at least two of four conditions, namely:
                                      (1) have serious public health impact; (2) be an unusual or
                                      unexpected event; (3) have significant risk of international spread;
                                      and (4) carry significant risk of travel or trade restrictions. (a) The
                                      Panel’s view is that the outbreak in Wuhan is likely to have met the
                                      criteria to be declared a PHEIC by the time of the first meeting of
                                      the Emergency Committee on 22 January 2020.
                                      While WHO was rapid and assiduous in its early dissemination of
                                      the outbreak alert to countries around the world, its approach in
                                      presenting the nature and level of risk was based on its established
                                      principles guided by the International Health Regulations of issuing
                                      advice on the balance of existing evidence. While WHO advised
                                      of the possibility of human-to-human transmission in the period
                                      until it was confirmed, and recommended measures that health
                                      workers should take to prevent infection, the Panel’s view is that it
                                      could also have told countries that they should take the precaution
                                      of assuming that human-to-human transmission was occurring.
                                      Given what is known about respiratory infections, there is a case

                               a In addition, SARS, poliomyelitis, smallpox and a new subtype of influenza are automatically
                                 defined as events that may constitute a PHEIC. See International Health Regulations (2005),
                                 3rd edition. Geneva: World Health Organization; 2016 (https://www.who.int/publications/i/
                                 item/9789241580496, accessed 26 April 2021).

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Credit: Watsamon Tri-yasakda

                                             for applying the precautionary principle and assuming that in any
                                             outbreak caused by a new pathogen of this type, sustained human-
                                             to-human transmission will occur unless the evidence specifically
                                             indicates otherwise.
                                             The Panel’s conclusion is that the alert system does not operate
                                             with sufficient speed when faced with a fast-moving respiratory
                                             pathogen, that the legally binding IHR (2005) are a conservative
                                             instrument as currently constructed and serve to constrain rather
                                             than facilitate rapid action and that the precautionary principle was
                                             not applied to the early alert evidence when it should have been.
                                             The Panel’s view is that the definition of a new suspected outbreak
                                             with pandemic potential needs to be refined, as different classes of
                                             pathogen have very different implications for the speed with which
                                             they are likely to spread and their implications for the type of
                                             response needed.

                                             4.2.3 Two worlds at different speeds
                                             The chronology of the early events in raising the alarm about
                                             COVID-19 show two worlds operating at very different speeds.
                                             One is the world of fast-paced information and data-sharing.
                                             Open digital platforms for epidemic surveillance, in which WHO
                                             plays a leading role, constantly update and share outbreak
                                             information. Digital tools are now core elements in disease
                                             surveillance and alert, sifting through vast quantities of instantly
                                             available information. Epidemic surveillance operates symbiotically
                                             with information exchange — the constant pace of news, gossip
                                             and rumour that characterize social media and can be mined
                                             for epidemic-relevant signals. Open data on the information and

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collaboration platforms central to scientific exchange also, by their
                                             nature, enable near-instant global availability of information.
                                             The other world is that of the slow and deliberate pace with which
                                             information is treated under the IHR (2005), with their step-by-step
                                             confidentiality and verification requirements and threshold criteria
                                             for the declaration of a PHEIC, with greater emphasis on action that
                                             should not be taken, rather than on action that should.
                                             The critical issue for this two-speed world is that viruses, especially
                                             highly transmissible respiratory pathogens, operate at the faster
                                             pace, not the slower one.
                                             The Panel’s conclusion is that surveillance and alert systems at
                                             national, regional and global levels must be redesigned, bringing
                                             together their detection functions — picking up signals of potential
                                             outbreaks — and their relay functions — ensuring that signals are
                                             verified and acted upon. Both must be able to function at near-
                                             instantaneous speed.
                                             This will require the consistent application of digital tools, including
                                             the incorporation of machine learning, together with fast-paced
                                             verification and audit functions. It will also require a commitment to
                                             open data principles as the foundation of a system that can adapt
                                             and correct itself.

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Credit: Christine McNab
4.3 Early responses lacked urgency and effectiveness
                                The declaration of a PHEIC by the WHO Director-General on 30
                                January 2020 was not followed by forceful and immediate emergency
                                responses in most countries, despite the mounting evidence that a
                                highly contagious new pathogen was spreading around the world. For
                                a strikingly large number of countries, it was not until March 2020, after
                                COVID-19 was characterized as a “pandemic”, and when they had already
                                seen widespread cases locally and/or reports of growing transmission
                                elsewhere in the world, and/or their hospitals were beginning to fill
                                with desperately ill patients, that concerted government action was
                                finally taken.

                                In recommending the declaration of a PHEIC on 30 January, the WHO
                                COVID-19 IHR Emergency Committee stated its view that it was “still
                                possible to interrupt virus spread, provided that countries put in place
                                strong measures to detect disease early, isolate and treat cases, trace
                                contacts and promote social distancing measures commensurate with
                                the risk” (38). Most countries did not seem to get that message, despite the
                                fact that, at the time, cases had been reported in 19 countries and human-
                                to-human transmission was reported in at least four countries in addition
                                to China. The majority of reported cases outside China had a history of
                                travel in China, but that was partly because testing was initially directed
                                only at those who both had symptoms and had recently travelled
                                from Wuhan.

  Figure 4: Cumulative COVID-19 cases by country as of 30 January 2020
  Source: World Health Organization Coronavirus (COVID-19) Dashboard. Data as of 21 April 2021.

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Figure 5: Cumulative COVID-19 cases by country as of 11 March 2020
  Source: World Health Organization Coronavirus (COVID-19) Dashboard. Data as of 21 April 2021.

                                On 30 January 2020, it should have been clear to all countries from the
                                declaration of the PHEIC that COVID-19 represented a serious threat.
                                China had reported upwards of 20 000 confirmed or suspected cases and
                                170 deaths. The number of countries to which the virus had spread and
                                where local transmission was occurring was growing by the day. Even so,
                                only a minority of countries set in motion comprehensive and coordinated
                                COVID-19 protection and response measures — a handful even before
                                seeing a confirmed case, and the remainder once cases had arrived.

                                The question we must ask ourselves is why the PHEIC declaration did not
                                spur more action, when the impending threat should have been clearly
                                evident? After a stuttering start to the global response in January 2020
                                by the end of that month it was clear that a full-scale response would be
                                needed. It is glaringly obvious to the Panel that February 2020 was a
                                lost month, when steps could and should have been taken to curtail the
                                epidemic and forestall the pandemic.

                                The Panel’s analysis suggests that the failure of most countries to respond
                                during February was a combination of two things. One was that they did
                                not sufficiently appreciate the threat and know how to respond. The second
                                was that, in the absence of certainty about how serious the consequences
                                of this new pathogen would be, “wait and see” seemed a less costly and
                                less consequential choice than concerted public health action.

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Credit: Rosem
        Mindy Tan
              Morton
4.3.1 Successful countries were proactive,
                                            unsuccessful ones denied and delayed
                                      The Panel’s review of a range of country responses up until March
                                      2021 (b) demonstrates that countries that recognized the threat of
                                      SARS-CoV-2 early, and were able to react comprehensively, fared
                                      much better than those that waited to see how the pandemic would
                                      develop. The early-responding countries acted in a precautionary
                                      way to buy time, while getting information from other countries,
                                      particularly from Wuhan in China where the impact of the lockdown
                                      showed that stringent measures could effectively stop the outbreak.
                                      Response models developed in relation to earlier outbreaks,
                                      including SARS and MERS, were rapidly adapted to the specific
                                      characteristics of this novel virus and its pathways of transmission.
                                      The 2003 SARS epidemic had left a permanent mark, especially
                                      in the most affected east Asian and south-east Asian countries.
                                      SARS resulted in governments instituting whole-of-government
                                      approaches with clearly defined, tiered command structures to
                                      prepare for and respond to future outbreaks, with clear involvement
                                      of communities and transmission of information. Health protection
                                      functions were consolidated under new centralized agencies.

                    Effective and high-level coordinating bodies were critical
                    to a country’s ability to adapt to changing information

                                      Even though Ebola virus disease is a very different type of disease
                                      to COVID-19, countries with that experience drew on it to rapidly
                                      establish coordination structures, mobilize surge workforces and
                                      engage with communities.
                                      National responses were most effective where decision-making
                                      authority was clear, there was capacity to coordinate efforts across
                                      actors, including community leaders, and levels of government, and
                                      formal advisory structures were able to provide timely scientific
                                      advice that was heeded. Effective and high-level coordinating
                                      bodies were critical to a country’s ability to adapt to changing
                                      information; in the context of a pandemic caused by a novel
                                      pathogen, adaptability has been vital.
                                      The strategies chosen by countries to respond to COVID-19 played
                                      out in very different ways. In analysing national responses, the
                                      Panel has identified three distinct strategic approaches: aggressive
                                      containment, suppression or mitigation. In addition, there are some
                                      countries without any discernible or consistently applied strategy.

                               b The Panel has conducted a review of policy responses in 28 countries selected to represent
                                 different regions and the best, worst and median outcomes, measured by deaths per
                                 100 000 population.

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